Just One Simple Form

Complete this one simple form to complete your entire Renewal. You do not have to complete every field. But the more detailed you are the more complete your renewal will be.

Company Basic Information

Please enter the basic information for your company. We are only as accurate as you are. We can catch glaring mistakes and reach out if we do, but your renewal documents will depend on you entering complete and accurate information.

If you leave fields blank they WILL NOT be completed on your forms.

This is for Texas DSHS EMS Provider Renewals ONLY

Contact Persons Name

Phone

Legal Entity Name

Which Company are You Renewing?

DBA-if any

Does your company have a DBA? If not you can skip this one.

EIN Number

This is your business EIN that is connected to your business. It is a 9-digit number XX-XXXXXXX

DSHS License Number

This is your ambulance provider license number.

Company's CEO

CEO's Address

Country/Region

Address

City

Zip / Postal code

CEO's Email

CEO's Phone

Administrator of Record-Name

Administrator of Record-Birthday

Month

Day

Year

Administrator of Record-TX EMS Certification Number or Social Security Number

Alternate Contact-Who can provide DSHS with answers of the Administrator is unavailable

Alternate's Address

Alternate's Email

Alternates Phone Number

Medical Directors Name

Medical Director's TX Medical License Number

Medical Director's Address

Vehicles

Vehicle Authorizations List the number of vehicle authorizations requested at each level and the total.

Do you have any Basic Level Support Units? BLS

Yes

If so how many? BLS

Do you have any Basic Level with Advance Level Support Units? BLS with ALS capability

Yes

If so how many?BLS-ALS

BLS with MICU Capability

Yes

If so how many? BLS-MICU

Advanced Life Support (ALS)

Yes

If so how many? ALS

ALS with MICU Capability

Yes

If so how many? ALS-MICU

Mobile Intensive Care Unit (MICU- Ground)

Yes

If so how many? MICU-Ground

Rotor-Wing (MICU)

Yes

If so how many? Rotor Wing

Fixed Wing (MICU)

Yes

If so how many? Fixed Wing

Any Specialized Units

Yes

If so how many? Specialized Units

How many TOTAL Units are you renewing

Provide the Unit # -VIN-Type (I, II, III)-License Number-Make Year-Category(BLS/MICU)

Provide the following for each vehicle you are renewing, if it is not completed it will not be added to your form.

1) Provide the Unit #

2) VIN(vehicle registration #)

3) Type(I, II, III)

4) License Tag Number

5) Make of Unit

6) Year of Unit

7) Category(BLS/MICU)

If you would rather upload a document with your vehicle information feel free and we will do the rest

Personnel

Any Deletions from your personnel

Any Additions to your personnel if so please provide their TDSHS EMS Personnel Certification/License Identification #-First and Last Name

If you would rather upload a document list of of additions or deletion please feel free and we will do the rest

Entity Type

If none apply please explain

Tax Status

Government Entity

For Profit

Non-Profit 501c3

If none apply please explain

Enter the Name and Title of all persons listed on the entity(all owners)

Response Type

Emergency/ 911

Non-Emergency/Non-911

Both

Does your organization offer a subscription program

Yes

Emergency Medical Task Force (EMTF) Participant

Yes

Letter of Credit

$100,000 for the initial & renewal of the license on the 2 anniversary

$75,000 for renewal of the license on the 4 license anniversary

$50,000 for renewal of the license on the 6 license anniversary

$25,000 for renewal of the license on the 8 license anniversary

Exempt - Governmental Entity

If non of these apply please explain

Do you have a Surety Bond

Yes

Bond Number

Bond Effective Date

Month

Day

Year

Name of institution issuing bond and contact telephone number

Service Area

Provide the City(s) and County(s) you plan to operate in

Pay Only for What You Need

Select all the renewal forms or just one

Which forms do you need?

Before you submit, check that your information is accurate. Whatever you enter-is what will be added to your forms. Documents are emailed within 24 hours after purchase or 4 hours if expedited. Once you receive your renewal forms no refunds will not be granted. Want to see how it works? Check the sample form and see how the process works before you commit to all your needed forms.(Note for the sample form to be completed you must enter at least some basic information)